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Cancer Scenario in India with Future


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Cancer Therapy Vol 8, page 56

Cancer Therapy Vol 8, 56-70, 2011

Cancer Scenario in India with Future Perspectives


Research Article

Imran Ali*, Waseem A. Wani and Kishwar Saleem


*Department of Chemistry, Jamia Millia Islamia (Central University), New Delhi-110025, INDIA

_______________________________________________________________________________
*Correspondence: Imran Ali, Department of Chemistry, Jamia Millia Islamia (Central University), New Delhi-110025, INDIA
Tel: 091-9211458226Fax 0091-11-26985507E-mail: drimran_ali@yahoo.com, drimran.chiral@gmail.com
Key words: Cancer, causes, preventive measures, economic effect, future perspectives.

Received: 15 October 2011; Revised: 26 October 2011


Accepted: 26 October 2011; electronically published: 1 November 2011

Summary
Among various diseases, cancer has become a big threat to human beings globally. As per Indian population census
data, the rate of mortality due to cancer in India was high and alarming with about 806000 existing cases by the end
of the last century. Cancer is the second most common disease in India responsible for maximum mortality with
about 0.3 million deaths per year. This is owing to the poor availability of prevention, diagnosis and treatment of
the disease. All types of cancers have been reported in Indian population including the cancers of skin, lungs,
breast, rectum, stomach, prostate, liver, cervix, esophagus, bladder, blood, mouth etc. The causes of such high
incidence rates of these cancers may be both internal (genetic, mutations, hormonal, poor immune conditions) and
external or environmental factors (food habits, industrialization, over growth of population, social etc.). In view of
these facts, the present article describes the status of various types of cancers in India and its comparison at global
level. Besides, attempts have been made to describe the main causes of cancer along with their preventive measures.
In addition to this, efforts have also been made to predict the effect of increasing number of cancer patients on the
Indian economy.

I. Introduction

the developing and under developed countries, which


may rise up to 70%; a serious issue for all of us. The
magnitude of cancer problem in the Indian Sub-continent
(sheer numbers) is increasing due to poor to moderate
living standards (Wynder et al, 1974) and inadequate
medical facilities. Most frequently observed cancers in
Indian population are of lungs, breast, colon, rectum,
stomach and liver (Nandakumar, 1990-96; Rao et al,
1998; Murthy et al, 2004). Nowadays, India is growing
with a good progress rate and probably will become a
developed country within a few decades resulting into its
participation in the world development. Therefore, it is
important to study the status of cancers in India so that
advance measures may be taken to control this havoc in
near future. In view of these facts, attempts have been
made to study the status of cancers in India including its
causes, preventive measures, effect on Indian economy
and comparison with global scenario.

In spite of good advancements for diagnosis and


treatment, cancer is still a big threat to our society
(Kotnis et al, 2005). This is the second most common
disease after cardiovascular disorders for maximum
deaths in the world (Jemal et al, 2007). It accounts for
about 23 and 7% deaths in USA and India, respectively.
The worlds population is expected to be 7.5 billion by
2020 and approximations predict that about 15.0 million
new cancer cases will be diagnosed; with deaths of about
12.0 million cancer patients (Brayand et al, 2006). The
prevalence of cancer in India is estimated to be around
2.5 million, with about 8, 00,000 new cases and 5,
50,000 deaths per annum (Nandakumar, 1990-96).
According to 1991 Indian census data, about 609000
cancer cases have been observed. This number had
drastically increased to 806,000 by the end of the last
century; with 96.4 and 88.2% age standardized rates for
males and females; out of 100,000 cases analyzed (Rao
et al, 1998). During last one decade, about 70% cancer
cases have been diagnosed and treated with survival of a
few patients (Dinshaw et al, 1999). It is believed that in
near future the number of cancer patients will increase in

II. Cancer scenario in India


A data of cancer patients was compiled from 2004 to
2010 in India and shown in Figure 1.

56

Cancer Scenario in India with Future Perspectives


Based on the increasing trends of cancer patients during
the last few decades, the numbers of cancer patients have
been predicted by the end of 2015 and 2020 in India.
These compiled data show that the number of male,
female and the total cancer patients in 2004 were
390809, 428545 and 819354 respectively. The number
of male and female cancer patients increased
continuously up to 2009, with 454842, 507990 and
962832 cases for male, female and total cancer patients,

respectively. Similarly, 462408 male cancer patients and


517378 female cancer patients were recorded, with a
total number of 979786 patients in 2010. Thus, it is clear
from this Figure that the number of cancer cases has
increased gradually with time. Moreover, a prediction of
cancer patients in 2015 and 2020, respectively, has also
been made. The different types of cancers observed in
India are discussed in the following sub-sections briefly.

Figure 1: Year wise total cancer prevalence in India [ICMR, 2006; ICMR, 2009].

A. Lung cancer

It is clear from this Figure that Delhi has the highest


number of total cancer cases among the five
metropolitan cities studied. Total numbers of cancer
patients reported in Delhi was 13920 having 6815 and
7105 males and females, respectively. Mumbai showed
the second highest number of cancer patients with 8505
total cases including 4170 and 4335 males and females,
respectively. Bangalore occupied the third position with
2262 and 2998 male and female patients, respectively
(total patients; 5250). Chennai stood at the fourth
position having 2296 and 2528 as male and female
cases; with a total number of 4824 cancer patients. Total
cancer patients were low in Bhopal (1255) with 701 and
554 males and females, respectively. These trends of
cancer patient distribution among discussed metropolitan
cities may be due to different levels of environmental
pollution, food habits, living style etc. Besides, the
population density in these cities may also be a
contributing factor towards increasing number of cancer
patients.

It was observed that lung cancer was rare in the


beginning of the last century (Parkin et al, 2000) but
later on it was diagnosed in various patients. Banker et
al. (Banker et al, 1955) reported about 9210 consecutive
autopsies of lung cancer patients in 1970, which were
14.4% of all cancer types. But, nowadays, it has become
almost epidemic resulting in greater number of deaths
than those caused by colorectal, breast and prostate
cancers (Khuri et al, 2001). The data collected by the
National Cancer Registry Program of the Indian Council
of Medical Research; from six different parts of the
country including both rural and urban areas; showed
varying degrees of incidence in different areas (ICMR,
1988-89).The most common forms of malignancies in
males during 1989 in Bombay, Delhi, and Bhopal were
cancers of trachea, bronchi and lungs. These cancers
were also reported in other cities in the order of Madras
> Bangalore > Barshi. These sorts of cancers were rare
in females except in Bombay and Bhopal, where they
ranked at sixth and seventh positions of malignancies,
respectively. Efforts have also been made to find out the
total number of cancer cases in five metro cities of India
(New Delhi, Bombay, Chennai, Bhopal and Bangalore)
during 2008. These data have been plotted in Figure 2.

57

Cancer Therapy Vol 8, page 58

Figure 2: Cancer prevalence in five metropolitan cities of India [Marimuthu, 2008].


Bhopal (3.4/105) and Barshi (1.2/105). In Mizoram,
AAR of stomach cancer has been found to be high in
both males (39.1/105) and females (14.4/105) as
compared to other parts of India. On the basis of the
prevalence of stomach cancer Mizoram occupied the
first position among Indian states. Moreover, this state
comprised fifth position globally (Figure 3) (Phukan et
al, 2004).

B. Breast cancer
Breast cancer is the most common malignancy type
diagnosed in women in developed countries and the
second most common type diagnosed in developing
countries. Breast cancer has been described as an
alarmingly health problem in India (Yeole et al, 2003).
According to the reports, breast cancers have badly
attacked women population in India. A survey carried
out by Indian Council of Medical Research (ICMR) in
the metropolitan cities viz. Delhi, Mumbai, Bangalore
and Chennai; from 1982 to 2005; has shown that the
incidences of breast cancer have doubled. Over the
years, the incidences of breast cancer in India have
steadily increased and as many as 100,000 new patients
are being detected every year (Yip et al, 2006; Michael
et al, 2003). A 12% increase has been registered by
cancer registries from 1985 to 2001, which represented
57% rise of cancer burden in India (Yip et al, 2006;
Hadjiiski et al, 2006).

D. Gall bladder cancer


Gall Bladder Cancer (GBC) was first diagnosed during
laparotomy or laparoscopy procedures, which were
expected to confirm the presence of benign gall bladder
diseases (Misra et al, 1997). Almost 2% gall stone
patients were diagnosed with GBC. Gall bladder cancer
is the most common abdominal malignancy in northern
parts of the country (Singh et al, 2004). An incidence
rate of 4.5 and 10.1% per 100 000 population of males
and females, respectively, has been reported by the
Indian Council of Medical Research Cancer Registry in
some northern parts of India (ICMR, 1996). The highest
incidence of GBCs in India has been reported along the
Ganges delta (Kaushik et al, 1997). Gallstones
associated with gallbladder carcinoma have been
reported in 70-90% of patients with GBC.
Approximately, 0.4% of all patients with gallstones have
GBC (David et al, 1997).

C. Stomach cancer
Stomach is one of the most essential organs of human
body, which frequently gets cancer and stands at fifth
position (Parkin et al, 1999). South East Asian countries
including India were reported to have lower rates of
stomach cancers (Rao et al, 1998; WHO, 2000-01).
However, the prevalence of stomach cancer was found to
be quite high in Mizoram, North East India. Reports
from the National Cancer Registry Programme
suggested that stomach remained the leading site of
cancer in males in Chennai from 1990 to 1996 with Age
Adjusted Rate [(AAR) =13.6/105], followed by
Bangalore (9.5/105), Mumbai (6.4/105), Delhi (3.9/105),

E. Cervical cancer
The most susceptible site of cancer in women in the
developing countries is cervix (Parkin et al, 1992).
During last few decades, it has been observed that the
number of cervical cancer cases in women has decreased
in India.
58

Cancer Scenario in India with Future Perspectives


One case study of Bangalore city supported this
observation. In 1982, 32.4% cervical cancer cases per
100,000 populations were reported every year in
Bangalore, which decreased to 27.2, 18.2, and 17.0% in
1991, 2001, and 2005 years, respectively. Similarly, in
1988, 25.9 new cases of cervical cancer per 100,000
women population were reported in Delhi, which
decreased to 19.1 and 18.9 in 1998 and 2005,
respectively. Accordingly, Mumbai recorded 17.9% new
cervical cancer cases per 100,000 populations in 1982
followed by 12.7% in 2005. During these 24 years
(1982-2005) Chennai recorded a fall of about 50% in
cervical cancer cases. According to the reports 41%
cases per 100,000 populations were reported in Chennai
in 1982, which decreased to 33.4 and 22.0% in 1991 and
2005.

III. Indian states and cancers


The state wise distribution of different cancer patients in
India is shown in Figure 3. A perusal of this Figure
clearly shows that lung cancer is the most common
cancer in various states. The most effected states of India
due to this cancer are Jammu & Kashmir, Himachal
Pradesh, Delhi, Uttarakhand, Rajasthan, Maharashtra,
Jharkhand, West Bengal, Andhra Pradesh, Kerala,
Tripura and Manipur. It is also clear from this Figure
that cervical cancer is the second most common form of
malignancy in female population of Himachal Pradesh,
Haryana, Rajasthan, Goa, Tamil Nadu, West Bengal
while it stands at third position in females of Punjab,
Andhra Pradesh and Uttar Pradesh. Breast cancer is the
most common form of cancer in the women of Himachal
Pradesh, Delhi, Rajasthan, Nagaland and Goa, and the
second most common form of malignancy in females of
Punjab, Maharashtra and Gujarat. In Tripura, breast
cancer represents the third most common form of cancer
in women folks. This Figure also dictates that stomach
cancer is the third commonly reported cancer in Sikkim,
Arunachal Pradesh, Tamil Nadu, Mizoram and Goa
sates. It is the second most common cancer in Andhra
Pradesh and Nagaland and the third most common type
of malignancy in Jammu & Kashmir. Oral cancer stands
at second and third positions in Goa and Assam states,
respectively. Head and neck cancer patients have been
observed in Tripura. Oesophageal cancer is a common
type of malignancy after lung cancer in Jammu &
Kashmir, Assam and Karnataka. Of course, Gall bladder
cancer is not frequent in India but it has been diagnosed
in certain parts of Punjab, Uttar Pradesh and Bihar.
Tongue cancer is the most common type of cancer in
Madhya Pradesh; especially in Bhopal while it stands at
second position in Goa. Oropharyngeal cancer is
prevalent in Haryana and Meghalaya. This Figure also
shows that some other types of cancers viz. skin,
laryngeal and non-Hodgkins lymphoma are rare in India
but some cases have been diagnosed in Chhattisgarh and
Uttarakhand. Cancers of ovary, prostate and brain have
been reported only at some places in Rajasthan. The
prostate and brain cancers were also found in males of
Rajasthan.

F. Oral cancer
In 2003, Indian Council of Medical Research (ICMR)
reported that oral cancer is very common in India
(ICMR, 1992). There has been a substantial increase in
the incidences of oral sub-mucous fibrosis; especially
among youngsters; which further increased the incidence
of the oral cancer (Gupta et al, 1998). Presently, oral
cancer is the fourth common type of malignancy after
lung, stomach and liver in males. It is the fifth common
cancer after cervix, breast, stomach and lung cancer in
females (Park, 1997). Regional Cancer Centre (RCC)
Kerala reported about 14% oral cancer patients out of
which 17.0 and 10.5% cases were in males and females,
respectively (Padmakumary, 2000). A significant
number of oral cancer patients have been reported in
Agra, Allahabad, Mainipuri, Varanasi and Moradabad
belt of Uttar Pradesh (Wahi et al, 1965).

G. Miscellaneous cancers
Besides these, some other sorts of cancers have been
observed in India. The incidence of esophageal cancer in
India is moderately high; associated with diets and
lifestyles. According to a data from cancer registries in
India, esophageal cancer is the second most common
cancer among males and the fourth most common cancer
among females (Gajalakshmi, 2001). Colorectal cancer
is a disease that usually affects individuals of age 50
years or more (Anthony, 1998). There is a sharp increase
in the incidence rate of colorectal cancer after the age of
45 years and 90% of cases are found in persons over the
age of 50 years (Lawrence et al, 2004). Head and Neck
Neoplasia (HNN) are major forms of cancers in India,
which account for nearly 23 and 6% in males and
females, respectively (ICMR, 1992). The five year
survival of the disease varied from 20-90% depending
on the sub-site of origin and the clinical extent of the
disease (Mehrotra et al, 2005). India is known to have
the worlds largest reported incidences of HNN in
women (Sankaranarayan et al, 1998). Nearly 0.2 million
head and neck cancer cases are diagnosed in the country
annually and approximately 4.5 million globally.

59

Cancer Therapy Vol 8, page 60

Figure 3: Statewise depiction of the most incident cancers in India [Koul, 2010; ICMR, 2001; Somdatta, 2008; Das, 2005;
Sharma, 2009; Gaur, 2006; Prasad, 2005; Malothu, 2010; Sumathi, 2009; (b) http//].

IV. Cancer causes in India

variation of cancer has been reported due to life styles


and food habits (Helbock et al, 1998). For example,
Asians have 25 and 10 times lower incidences of
prostate and breast cancers, respectively, as compared to
Western countries which may be attributed to
comparatively simple life styles adopted by Asians, and
safe sexual practices. It is interesting to mention here
that the rates of these cancer incidences increase
substantially when Asians migrate to the Western
countries; indicating a clear relationship of
carcinogenesis with food habits and living styles. The
various cancer causes have been compiled by visiting
various hospitals, cancer agencies and institutes and
plotted in Figure 4. Some important causes of cancer in
India are discussed in the following sub-sections briefly.

The cancer causes in India are almost same as in other


parts of the world. The chemical, biological and other
environmental identities are responsible for uncontrolled
and unorganized proliferation of cells (carcinogens).
Basically, under special circumstances carcinogens
interact with DNA of the normal cells resulting into a
series of complex multistep processes responsible for
uncontrolled cell proliferation or tumors (Carmaeia,
1993). The causes for cancers can be both either internal
factors like inherited mutations, hormones, and immune
conditions or environmental factors such as tobacco,
diet, radiation, and other infectious agents. A significant

60

Cancer Scenario in India with Future Perspectives

Figure 4: Etiological factors for the prevalence of different cancers in India [Koul et al, 2010; ICMR, 2001;
Somdatta et al, 2008; Sharma et al, 2009; Gaur et al, 2006; Prasad et al, 2005; Malothu et al, 2010; Sumathi et al,
2009; (b): http//].

A. Dietary habits

Most probably, it is due to the production of heterocyclic


amines(most potential carcinogens) during cooking of
red meat. Pyrolysates are produced by charcoal cooking
or smoke curing of meat, which exert a cancerous effect
on our body cells (Lauber et al, 2007). Almost 20% of
total mutagencity of fried beef is due to the presence of
PhIP (2-amino-1-methyl-6-phenyl-imidazo [4, 5-b]
pyridine), which is the most abundant mutagen by mass
in cooked beef. Food kept in plastic containers turns out
to be carcinogenic because bios-phenol from the plastic
containers gets dissolved and migrates into the food;
resulting into the risk of breast (Durando et al, 2007) and
prostate (Ho et al, 2006)cancers. A low intake of fresh
fruits and high cooking temperatures in Indian dishes
may account for low levels of vitamin C; resulting into

Our survey dictates us that improper diet is one of the


main causes of cancer prevalence in India. About 70%
colorectal cancer cases are believed to be due to
imbalanced diet. The role of diet towards cancer varies
greatly according to the type of cancers (Anand et al,
2008; Willett, 2000). As per the International correlation
studies, overwhelming positive associations between
dietary fat, red meat consumption and colorectal cancer
incidence and mortality have been observed. The heavy
consumption of red meat is the main cause of several
cancers including gastrointestinal tract and colorectal
(Binghamet al, 2002; Chao et al, 2005; Hogg, 2007),
prostate (Rodriguez et al, 2006), bladder (Garcia-Closas
et al, 2007), breast (Tappel, 2007), gastric (Hanlon,
2006) and oral cancers (Toporcov et al, 2004).

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Cancer Therapy Vol 8, page 62


higher risks of stomach, mouth, pharyngeal, esophageal,
2003). Recently, the case control studies carried out in
Asian Indian immigrants to U.K. and U.S.A. found high
levels of homocysteine as a risk factor for the breast,
ovarian and pancreatic cancers (Wu et al, 2002).
Vegetarianism; practiced by a large population of
Indians (particularly Hindus); has been associated with
lower risks of prostate cancer (Rajaram et al, 2000). A
comparison of non-vegetarian and vegetarian diets and
alcohol and tobacco uses in India was carried out
through case control studies. It was observed that
vegetarians have a lower risk of esophageal (Roa, 1997),
oral (Roa et al, 1994) and breast cancers (Jain et al,
1999). Beans, chickpeas and lentils are the principal
components of vegetarian diet- a rich source of proteins;
and pulses have been significantly associated with
reductions in cancer (Jain et al, 1999; Mills et al, 1989).
An increased risk of cancer has been observed with diets
with high saturated fats. Middle class people in India and
some of the rural areas have a high intake of ghee, which
may create an increased cancer risk (Ghafoornissa, 1998;
Law, 2000). The Indian diet containing adequate
quantities of vegetables, fruits, and fibre rich grains
provides protection against the increased risk of colon
and breast cancers (World cancer research fund, 1997).
Furthermore, Figure 4 depicts that improper life style
and poor dietary habits, which are the key factors for the
prevalence of breast and cervical cancers in the female
population of Goa. High incidences of throat and food
pipe cancers in Andhra Pradesh and Assam were
attributed to improper diets (Lammers et al, 1998).

lung, pancreas, and cervical cancers (Chandalia et al,


al, 2009). Bidi smoking at two puffs per minute produces
about equal amounts of carcinogens (steam volatile
phenols, hydrogen cyanide and benzopyrene) as
produced by one puff per minute of unfiltered cigarette
(Pakhale et al, 1990). Hookah (a special cigar used in
India using raw tobacco) smoking causes lung cancer; as
reported by Nafae et al. (Nafae et al, 1973). Recently,
Gupta et al. (Gupta et al, 2001) reported 80 and 33%
lung cancers in men and women chain smokers,
respectively, as compared to controlled subjects where
these numbers were 60 and 20%. Besides, Figure 4
shows that cigarette smoking and Hookah are the main
causes of lung cancer in Indian states; especially in
Jammu and Kashmir, Himachal Pradesh, Uttarakhand,
Manipur, Tripura and some parts of Sikkim. Similarly,
bidi and hookah smoking are responsible of
oropharyngeal cancers in male population of Haryana.
Bidi and cigarette smoking are thought to be etiological
factors for the causation of cancers in Andhra Pradesh.
In some north-eastern states of India such as Arunanchal
Pradesh, Nagaland and Sikkim, high incidences of
stomach cancer are attributed to the consumption of
smoked meat and chewing of tobacco. High incidences
of stomach cancer in Mizoram are the result of the
excessive use of tuibur (water filterate of tobacco).
Similarly, high incidences of oral cancers in Orissa and
Madhya Pradesh are owing to the consumption of beetle
leaves and tobacco in different forms. The relatively
high incidences of oesophageal cancers in certain parts
of Karnataka are because of heavy consumption of
tobacco in various forms.
Figure 4 also depicts that the exceptionally
high incidences of oral cancer in some parts of Uttar
Pradesh and Gujarat are due to the consumption of Pan
Masala, Dohra and Zarda. Similarly, the consumption of
Beetal, Nut, Pan Masala, Opium and Bhang (leave and
flower powder of female cannabis plant) has been
recognized as the major cause of mouth cancer in
Rajasthan. Oral cancer being the common malignancy in
Allahabad is attributed to the chewing of Dohra; an
indigenous preparation of tobacco and slaked lime. The
daily consumption of the number of beetle leaves by an
individual is about 15-25 in Allahabad and Varanasi
districts, which continuously acts as an irritant to the
buccal mucosa (Mehrotra et al, 2003). One of the most
important factors responsible for the oropharyngeal
malignancy in Agra and Mainpuri belt of Uttar Pradesh
is the chewing of beetle nut (Wahi et al, 1965). Among
various risk factors for the occurrence of esophageal
cancer in India, betel quid chewing carries a relative risk
of 1.5 to 3.5%. The salted tea made by adding sodium
bicarbonate has shown to possess a high methylation
activity and may lead to the endogenous formation of
nitrosamine (Malkan et al, 1997).

B. Tobacco
The consumption of tobacco is the leading cause of
cancers in India. Figure 4 shows the regular use of
tobacco via smoking, chewing, snuffing etc. in some
areas of the country, which is responsible for 65 to 85%
cancer incidences in men and women, respectively. The
various cancers produced by the use of tobacco are of
oral cavity, pharynx, esophagus, larynx, lungs and
urinary bladder. It has been observed that women in
Bangalore are known to have the highest rates of cancers
of esophagus in the world (around eight per 100,000).
Contrarily, men in Bhopal have the highest rate of
tongue cancer in the world (nine per 100,000) (Bobba et
al. 2003). Smoking is the most notorious factor for the
causation of lung cancer (Hammond et al, 1958).
Approximately, 87 and 85% males and females have
been found to have lung cancer due to tobacco smoking
in the form of bidi (a thin South Asian cigarette type
structure filled with tobacco flake and wrapped in a
tendu leaf, tied with a string at one end) (Behera et al,
2004) and cigarette in India (Notani et al, 1974). The
severe carcinogenic nature of bidi has been proved by
the studies of Jussawalla and Jain (Jussawalla et al,
1979) and (Pakhale et al, 1985). They observed that the
unrefined form of tobacco used in bidis (WHO, 1999)
and the frequency with which a bidi needs to be puffed
per minute may be responsible for its relatively higher
carcinogenic effects as compared to cigarettes (Bano et

C. Alcohol
Alcohol consumption has been considered as one of the
major causes of colorectal cancer as per a recent
monograph of WHO (Baan et al, 2007).
62

Cancer Scenario in India with Future Perspectives


Annually, about 9.4% new colorectal cancer cases are
attributed to the consumption of alcohol, globally
(Parkin et al, 2002). An increased risk of 10% was
observed with consumption of more than two drinks per
day, which suggests a causative role of alcohol
consumption in colorectal cancer (Toriola et al, 2008).
Recently, a study revealed that an increased risk of
colorectal cancer was limited to consumption of more
than 30.0 g of alcohol per day (Longnecker et al, 1990).
Relationship between alcohol consumption and high risk
of oesophageal cancer was first known in 1910 (Tuyns,
1979). However, chronic alcohol consumption has been
found to be a risk factor for the cancers of the upper
respiratory and digestive tracts, including oral cavity,
hypopharynx, larynx and esophagus as well as liver,
pancreas, mouth and breast cancers (Tuyns, 1979; Maier
et al, 1994; Seitz et al, 2004; Doll et al, 1981). A 10.0
g/day intake of alcohol by a woman increases its relative
risk of breast cancer by 7.1% (Doll et al, 1981). The
mechanism of carcinogenesis due to alcohol
consumption is not exactly known, however, it is
thought that ethanol being a co-carcinogen might play a
crucial role in the carcinogenesis (Poschl et al, 2004).
The metabolic products of ethanol are acetaldehyde and
free radicals. The free radicals are responsible for
alcohol assisted carcinogenesis through their binding to
DNA and proteins, which destroy foliate leading to
secondary hyper proliferation (Anand et al, 2000).

effects of the polluted environment. The risk of lung


cancers is increased by a number of outdoor pollutants
such as poly aromatic hydrocarbons. Long term
exposure to PAHs (polyaromatic hydrocarbons) in air
was found to increase the risk of deaths associated with
lung cancer. Indoor environmental pollutants such as
volatile organic compounds and pesticides increase the
risk of leukemia and lymphoma, brain tumors, Wilms
tumors, Ewings sarcoma and germ cell tumors. An
increased risk of cancer has been observed in people
using chlorinated water for drinking purposes for a long
time. N-Nitroso compounds (mutagenic in nature) are
formed from nitrates present in drinking water and
increase the risk of lymphoma, leukemia, and colorectal
cancer and bladder cancers (Belpomme et al, 2007).
Figure 4, also shows that high level of air pollution is
responsible for the prevalence of lung cancers in Delhi
and some other parts of West Bengal including Calcutta.
The low socio-economic conditions related to poor
hygiene, poor diet or infections of viral origin are also
responsible for various types of cancers (Mehrotra et al,
2003).

V. Preventive measures of cancer in


India
As per the proverb, prevention is better than cure the
prevention strategies are crucial in cancer eradication.
This approach offers a great public health concern and
inexpensive long term method of cancer control.
National Cancer Control Programme (started in 19751976 in India) led to the development of Regional
Cancer Centers (RCCs), a number of oncology wings in
Medical Colleges; supported the purchase of teletherapy
machines. District Cancer Control Programme was also
initiated but could not result into sustainable and
productive
activity
(National
Cancer
Control
Programme). The education should focus on harmful
effects of tobacco and discourage its use. Besides, we
should create awareness among public about physical
activities, avoiding obesities, healthy dietary practices,
reducing occupational and environmental exposures,
reducing alcohol uses, immunization against hepatitis B
virus and safe sexual practices for avoiding cancer
genesis (Dinshaw et al). The same approach should be
included in adult education programme. Several state
wise programmes like Kerala (Ten year action plan),
Tamil Nadu (Kancheepuram Cancer Screening
Programme) and opportunistic programmes in social
regions have been implemented by some State
Governments and Regional Cancer Centers (RCCs) for
an early detection of different cancers in India. The
predicted results were not materialized in most of the
programmes except RCC programme in Trivandrum as
the health service system could not support such
activities due to deficiencies in health system
management and non-availability of human resources
(Cytologists /Pathologists) and absence of integration
with multi-sectoral groups. Unfortunately, a little
population got aware of cancer havoc, which might be
spread to the population of the whole country (National
Cancer Control Programme).

D. Radiation
In the developed and developing countries, the radiations
are also notorious carcinogens. About 10% cancer
occurrence is due to radiation effect, both ionizing and
non-ionizing (Belpomme et al. 2007). The major sources
of radiations are radioactive compounds, ultraviolet
(UV) and pulsed electromagnetic fields. The main series
of cancers induced by exposure to the adequate doses of
the carcinogenic radiations include thyroid, skin,
leukemia, lymphoma, lung and breast carcinomas. The
most common source of ionizing radiation exposure is
Radon, which is a radioactive element. Radioactive
nuclei of radon, radium and uranium are found to be
associated with an increased risk of gastric cancer in
rats. High risk of breast cancer among girls at puberty is
due to chest irradiation of X-rays (used for diagnostic
and therapeutic purposes). The major risk factor for
various types of skin cancers viz. basal cell carcinoma,
squamous cell carcinoma and melanoma is the exposure
to ultraviolet light, which is a non- ionizing radiation
(Anand et al, 2000). The underground testing of nuclear
weapons may be the major cause of digestive system,
liver and kidney cancers, as radiations have been
reported in ground water of the nuclear weapon testing
area. Moreover, Figure 4 clearly shows that nuclear
pollution is the main cause of lung cancer in Jharkhand.

E. Miscellaneous pollutants
It is estimated that about 90% cancer is owing to the
environmental contaminants (Anand et al, 2000).
Various types of cancers are believed to be due to ill
63

Cancer Therapy Vol 8, page 64


As discussed above tobacco is the most notorious agent
for cancers, which must be banned to eradicate the
prevalence of tobacco related cancers. India should give
the highest priority to tobacco control programme due to
its acute carcinogenic nature (WHO, 2002). It has been
predicted that a ban on tobacco use can prevent up to
30% cancers in India (Central Statistical Organization,
2003-04). Alcohol consumption is responsible for the
occurrence of colorectal cancer. About 25% population
is consuming alcohol in India, which must be minimized
or avoided to eradicate this havoc. Government needs to
impose a ban on the public sale of alcohol. Seminars and
public health camps should be conducted to create
awareness of alcoholic harmful effects among Indians.
Radiations are silent and serious carcinogens that cause a
number of cancers and, hence, the strategies that reduce
the exposure of people to these notorious radiations
should be fully practiced to reduce the incidence of
cancers. India being one of the nuclear power nations
needs to build safe equipped nuclear plants with greater
protection from the hazardous nuclear radiations.
Nuclear reactors should be well constructed with good
quality shields to provide more protection to the people
at work. Nuclear tests should be carried out at safe
places away from human populations to avoid exposure
to these radiations.
Environmental pollution is a serious issue and has
become a challenge for all of us as it is responsible for
the genesis of various types of cancers. Air pollution is
the most notable cause of lung cancer in the metropolitan
cities of India. The harmful gases such as carbon
monoxide (CO) and sulphur dioxide (SO2) produced by
combustion of fuels in automobiles and several industrial
processes, respectively, cause lung cancer, respiratory,
digestive, ocular and skin carcinomas. Automobiles that
run on compressed natural gas (CNG) should be
encouraged; at least in the metropolitan cities of the
country to avoid air pollution. The use of
chlorofluorocarbons (CFCs), methyl halides, carbon
tetrachloride and carbon tetra fluoride is the main cause
of the depletion of ozone layer, which protects us from
the harmful UV-rays. The use of such chemicals should
be minimized in order to reduce the incidence of skin
cancer caused by the harmful effects of UV-rays. The
sewage discharged by several industries and
municipalities is polluting Indian water resources due to
insufficient water treatment plants; leading to various
types of cancers. Therefore, these wastes should be
treated prior to their discharge to land or river.
Due to over growth of Indian population, farmers are
compelled to produce more cereals and vegetables to
meet out public requirements. This pressure forces
farmers to use excessive fertilizers and pesticides, which
are being transported into our body via food and water
causing various sorts of cancers. Farmers should be
encouraged to use eco-friendly organic manures and
biocides to reduce cancer incidences. India is a
developing country and gradually adopting modern life
styles involving the use of various kinds of chemicals in
terms of medicines, cosmetics, cloths, utensils, mobile
phones and other luxurious items. The use of such items

may cause different sorts of cancers. That is why during


past few decades the incidences of cancers have
increased. It is urgent to emphasize that Indians should
be aware about their life styles particularly the use of
synthetic products, fabric dressing, and mode of sex,
abuse of drugs and excessive use of mobile phones.
Besides, an increased fashion of fast food in this country
is also responsible for this havoc. Indians should adopt a
healthy food habit having sufficient quantities of
vitamins, minerals, proteins, fibers, carbohydrates etc.
The healthy and proper foods are important aspects to
control different cancers. The consumption of whole
grains, vegetables and fruits antagonize the development
of some cancers. The effects of various foods on the
prevention and eradication of different cancers are given
in Table 1. Briefly, there are no uniform standardized
information programs, education and communication
(IEC) strategies for cancer prevention in this nation.
Besides, limited diagnostic and treatment infrastructures
in the country are the serious issues, which must be
increased on urgent basis. The government and other
NGOs should come forward to initiate the above
programs for controlling this havoc so that the present
and coming generation of the country may lead healthy
life.

VI. Effect of cancer on Indian


economy
As per nominal Gross Domestic Product (GDP),
the economy of India stands on eleventh position in the
world, while it is fourth largest by Purchasing Power
Parity (PPP) (CIA-The World Factbook, 2009). Indians
are at high risk of acquiring cancers due to high rates of
smoking, tobacco use, occupational risks, and
unhygienic residential living conditions. The prevalence
of cancer in India is affecting the economy of the
country. The data on the effect of cancer on Indian
economy is not available; however, Popkin et al. (2001)
assessed the impact of cancer of diet related health
conditions in terms of health spending and on income
losses experienced by households (Popkin et al, 2001).
The estimation of expenditures of cancer patients
includes both direct medical and non-medical costs. The
direct costs include buying medicine, hospitalization,
pathological tests, medical practitioner consultancy,
travel, lodging while the indirect costs are loss of income
during treatment, premature death and affect on the
income of other family members etc.
In 2007,
Abegunde et al. calculated the effect of cancer deaths on
Indian economy. Furthermore, they assessed the
economic impact of mortality from chronic diseases on
Gross domestic product (GDP) (Abegunde et al, 2007).
Briefly, Indian economy has been affected by the
alarming rise of cancers in the last decade. It is still
being affected due to continuous increase of cancer
patients. An estimation of the effect of cancer on the
Indian economy has been carried out and the data is
given in Table 2. The economical loss was calculated by
considering all the factors viz. both direct medical and
non-medical costs. It is clear from Table 2 that there is a
steady rise in the number of cancer cases in India. This
64

Cancer Scenario in India with Future Perspectives


Table also shows that the total number of cancer patients
in 2004 was 819354 with a total loss of 215.16 million
US $. The number of cancer patients and economic loss
are continuously increasing, which have become 962832
and 274.10 million US $ by the end of 2009,
respectively. Similarly, the total cancer patients in 2010
were 979786 with total economic loss of 270.06 million
US $. Clearly a direct relationship between the number
of cancer patients and the economic loss may be seen

from this Table. It is interesting to mention if these


cancer incidences would have been avoided; by adopting
the preventive measures cited above; India would not
have suffered from such a big economic loss. This
amount of money would have been used somewhere else
for the development of the country.

65

Cancer Therapy Vol 8, page 66


compared to USA (4.9 and 1.4) for males and females,
respectively. High incidences of these two types of
cancers can be attributed to the extensive use of tobacco
by Indians in the form of Pan, Masala, Gutka, Zarda etc.
A slightly high incidence rate of stomach cancers was
reported in USA (7.3 and 3.6 in males and females per
100000 populations) as compared to India (5.7 and 2.8 in
males and female per 100000 populations), respectively.
High rates of lung and colon cancers were reported in
USA in comparison to India. This Figure also clearly
shows that the incidences of lung cancer in USA being
58.6 and 34.0; in males and females per 100000
populations, which is much greater than India (9.0 and
2.0 for males and females per 100000 populations).
Similarly, incidence rate of colon cancer (40.6 and 30.7
for males and females per 100000 populations) in USA
was greater than in India i.e. 4.7 and 3.2 for males and
females per 100000 populations, respectively. This
Figure also depicts high incidence rates of liver, bladder,
kidney and skin cancers in USA as compared to India.
The incidence rates of liver, bladder, kidney cancers and
melanoma of the skin in males and females in India were
2.3 and 2.0, 3.2 and 0.7, 1.2 and 0.5, 0.3 and 0.2
respectively, which were lower than the incidence rates
of the same cancers in USA i.e. 4.2 and 1.7, 23.4 and
5.4, 11.2 and 6.0, 4.2 and 1.7 per 100000 populations in
males and females, respectively. In United States the age
specific incidence of colorectal cancer appears to rise
gradually from second to ninth decade of an individuals
life. The incidence of rectal cancer in men is
proportionately higher as compared to women (Parkin et
al, 1999). In US, genetic and familial etiologies
accounted for less than 20% of colorectal cancers while
the remaining 80% of cases are random with dietary
factors significantly affecting the risk (Alabaster, 1972).
Contrarily, the numbers of colorectal cancer patients in
India by the end of the last century were 18,427 and
13,092 in men and women, respectively (Mohandas et al,
1999).

VII. Comparison of cancers in


India with global scenario
It is interesting to observe from the above discussion that
cancer prevalence patterns have been observed to vary
among different population groups within the same
country (WHO, 1993). Nearly ten million new cancer
cases are diagnosed annually in the world and out of
these about half cases are from developing world only. It
is predicted that by the end 2020, over 10 million people
would die globally each year because of cancer with
70% deaths from the developing countries only (Murray
et al, 1996). But it is very interesting to note that World
Health Organization has reported that the current cancer
incidence rates in India are considerably lower than
those in developed countries including USA (Fenley et
al, 2001). Lung cancer is the single most devastating
cause of cancer related deaths (Khuri et al, 2001). A
great variation is observed in the prevalence of lung
cancer in different geographical areas. The worldwide
incidences of lung cancer are 14% whereas it constitutes
6.8% of all cancers in India (Nandakumar, 2001). Some
countries like USA, Canada, New Zealand (Maori
population) and Europe have high incidences of cancer
(>50 per 105 population) followed by China, Ireland,
Malta, Spain, Australia and New Zealand (non-Maori
population) while moderate incidences (35-50 per 105
population) and low incidences (<35 per 105 population)
countries include Latin America, most Asian countries
with India, Iceland, Norway and Sweden (Zelenuich et
al, 2005). Lung cancer is the most frequent tumor in
males, and second or third most common in females. In
US alone, there were about 1, 64,100 new cases in 2000,
of which 70,000 were in the metastatic stage (stage IV)
and another 70,000 were locally advanced stages (IIIA
and IIIB) (Khuri et al. 2001). A high incidence of
stomach cancer has been reported in countries like
China, Japan, Republic of Korea, Belarus and CostaRica whereas the highest age adjusted rate (AAR) of
145.0/105 was reported among males of Changle, China
and among females of Japan with age adjusted rate
(AAR) of 38.9/105 (Parkin et al, 1999; Parkin et al,
2002). South East Asian countries including India were
reported to have lower incidence rates of stomach cancer
(Parkin et al, 1999; WHO, 2000-01). However, in
Mizoram a North-Eastern part of India, medical
practitioners observed a very high prevalence of stomach
cancer (Hadjiiski et al, 2006).
A comparison of cancer cases in India with USA has
been carried out for the year 2002 as shown in Figure 5.
The Figure clearly shows that the incidences of oral
cancer in Indian males and females were 12.8 and 7.5
persons per 100000 populations, which were quiet
higher than the incidences of the same type of cancer in
males and females in USA (6.3 and 3.7 persons per
100000 populations), respectively. Similarly, high
incidences of oesophageal cancer in Indian populations
were observed as compared to USA. It was also
observed that incidence rates of 7.6 and 5.1 of
oesophageal cancer (in a population of 100000 persons)
of males and females were observed in India as

VIII. Conclusion
A careful reading of the above discussion in this article
clearly indicates an increased number of cancer patients
every year in India. Various factors responsible for
cancer genesis have been discussed, which need to be
controlled for their eradication. India is a growing
country playing a crucial role in the development of the
whole world, and, hence, needs special attention on this
issue. We should create awareness among public about
the cancer havoc and its prevention. The different
programs should be started by Government and NGOs
for creating awareness among Indian public. The diet
and living style are important factors to control the
spreading of cancers and, hence, Indians should be
careful about these facts. Briefly, cancer is disturbing the
growing economy of the country, which can be saved by
proper handling of this disease. In view of these facts, it
is very important to eradicate this havoc. Let us hope for
the best future of this country, which is playing an
essential role in the development of the whole world.

66

Cancer Scenario in India with Future Perspectives

Figure 5: Comparison of cancer; Indian scenario with USA [Fenley et al, 2001].

Acknowledgement
The authors are thankful to University Grants
Commission (UGC), New Delhi for providing UGCBSR research fellowship to Mr. Waseem Ahmad Wani.

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Dr. Imran Ali

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